There's no way around it, lung cancer is a tough challenge. It may not be the most commonly diagnosed cancer in the United States, but it is particularly deadly, according to Dr. Randy Becker, a radiologist who practices at Advanced Radiology in Westminster.

"We know that lung cancer is the third-most common cancer diagnosis in the U.S. currently, with upward of 220,00 patients diagnosed each year," Becker said. "Unfortunately, we also know that lung cancer mortality is the highest of any cancer diagnosis in the U.S. If we take the top three cancers — colon, breast and prostate — and you add up the number of individuals who perish from those types of cancers, it's still less than the number who die from lung cancer."

One of the reasons for that high mortality, Becker said, is that lung cancer is often only detected once it has reached an advanced stage, stage three or four, and spread to other organs, making treatment difficult and "unfortunately, the five-year survival rate of patients with stage three or stage four is often in the single digits, less than 10 percent."

In 2013, the National Lung Screening Trial compared the use of standard chest X-rays with low-dose Computer Tomography scans for the early detection of lung cancer. The study, Becker said, showed that "if we did reduced-dose or low-dose CT, we could actually diminish the number of cancer-related deaths from lung cancer by 20 percent, so that was significant."

What that means in practice is that Advanced Radiology wants to bring in those people at the highest risk of developing lung cancer — those ages 55 to 77, who have smoked a pack of cigarettes a day for at least 30 years, but are currently showing no symptoms of lung cancer — and begin an annual screening process using the low-dose CT scan. Those who show negative results from the screening will return in one year for a follow-up, Becker said, while patients who exhibit something concerning in the low dose CT will return in six months or less to receive a diagnostic chest X-ray that will look more closely at the lungs and surrounding organs.

A diagnostic chest X-ray, is also what a smoker who is showing possible symptoms of lung cancer, such as coughing up blood, might be directed to do by their doctor, according to Becker. Those individuals would not benefit from a screening program designed to catch cancer early enough that there might be no symptoms, he said.

KEN KOONS/STAFF PHOTO / Carroll County Times

Randy Becker reads catscans at Advanced Radiology in Westminster on October 4, 2016.

"The goal of any screening program is not to screen everybody," Becker said. "If we can target that very narrow population of high-risk individuals, and detect any kind of malignancy or any kind of problem at an earlier stage, we're going to be that much more likely to have a positive result in treatment for the patient."

And screening programs, as they currently exist, are not without risks, according to Becker, and he and his colleagues spend a great deal of time making sure prospective patients understand the cost-benefit analysis of participation.

"There are, in any screening program, whether it's mammography or low-dose CT, you will have false positives," he said. "A false positive is when you see something on an exam and you think it's, in this case, cancer, when in fact it's not. What does that mean for the patient? It could mean extra CT scans, it can mean extra biopsies, it can mean unnecessary treatments."

That risk of false positives and unnecessary treatments, and the costs involved, is one reason why low-dose CT screening is not appropriate for all individuals with any risk of lung cancer, according to Becker. It may be possible that future advances will change that protocol and make lung cancer detection easier at earlier stages and for people in lower risk categories, something like a blood test or a throat swab that could be done in a physician's office, but such technologies are not available today, he said.

There is some progress being made on that front however.

At the University of Hawaii Cancer Center, researchers have discovered that people with a specific variation in the CYP2A6 gene metabolize nicotine faster, and therefore may consume more tobacco to get the amount of nicotine they need, placing them at greater risk of developing cancer. If the researchers can show that high levels of the enzyme associated with the CYP2A6 gene do, in fact, predict a higher risk of developing lung cancer, a simple urine test for this enzyme could help identify those at highest risk, according to Dr. Loïc Le Marchand, a professor at the Cancer Center.

"We will assess whether using a high CYP2A6 activity as a criterion for lung cancer screening helps in decreasing the rate of false positives. This would make screening more cost efficient by better identifying individuals who truly are at high risk and should be screened," he wrote in an email. "There is no other screening modality for lung cancer at the present time, so better prediction of risk would be a major improvement for CT scan screening."

At Johns Hopkins School of Medicine, there are several different technologies being used in a research setting that could one day provide a more generalized test for the early detection of lung cancer, according to Dr. Lonny Yarmus, research director for the Johns Hopkins Interventional Pulmonary Lung Cancer Program.

There are blood tests and tests using cells scrapped from a patient's airway that can be used to determine how likely a pulmonary nodule discovered through screening is to be malignant, Yarmus said. There are also breath analysis techniques, he said, where the volatile organic compounds exhaled in breath may one day be correlated with cancer risk.

The goal with each of those technologies, Yarmus said, is to allow patients to go in to their doctor's office and "get their exhaled breath test or their blood test for lung cancer Iike they get their PSA and mammogram."

KEN KOONS/STAFF PHOTO / Carroll County Times

Randy Becker reads catscans at Advanced Radiology in Westminster on October 4, 2016.

It could be as soon as a year or two before blood tests for gauging the malignancy of a discovered pulmonary nodule is ready for clinical application and integrated into screening guidelines, Yarmus said. But for a breath analysis test that could enhance or even supplant low dose CT screening? That, he said, could take five or 10 years.

In the meantime, the screening program available at Advanced Radiology represents the best evidence-based lung cancer screening available, and, according to Becker, it's having a significant impact.

"We are already seeing the needle starting to move from 50 to 60 percent [of lung cancers] diagnosed at an early stage, moving that up to 70 or 80 percent. Then, on the flip side, where the five-year survival is less than 10 percent, we are already starting to see that move up to 15 percent, 20 percent," he said. "I think what we are doing right now, from an imaging perspective, is an exceptional screening program for our patients at high risk for lung cancer."

jon.kelvey@carrollcountytimes.com

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